Prevention of stress-related ulcer bleeding at the intensive care unit: Risks and benefits of stress ulcer prophylaxis

Abstract

Stress-related mucosal disease is a typical complication of critically ill patients in the intensive care unit (ICU). It poses a risk of clinically relevant upper gastrointestinal (GI) bleeding. Therefore, stress ulcer prophylaxis (SUP) is recommended in high-risk patients, especially those mechanically ventilated > 48 h and those with a manifest coagulopathy. Proton pump inhibitors (PPI) and, less effectively, histamine 2 receptor antagonists (H2RA) prevent GI bleeding in critically ill patients in the ICU. However, the routine use of pharmacological SUP does not reduce overall mortality in ICU patients. Moreover, recent studies revealed that SUP in the ICU might be associated with potential harm such as an increased risk of infectious complications, especially nosocomial pneumonia and Clostridium difficile-associated diarrhea. Additionally, special populations such as patients with liver cirrhosis may even have an increased mortality rate if treated with PPI. Likewise, PPI can be toxic for both the liver and the bone marrow, and some PPI show clinically relevant interactions with important other drugs like clopidogrel. Therefore, the agent of choice, the specific balance of risks and benefits for individual patients as well as the possible dose of PPI has to be chosen carefully. Alternatives to PPI prophylaxis include H2RA and/or sucralfate. Instead of routine SUP, further trials should investigate risk-adjusted algorithms, balancing benefits and threats of SUP medication in the ICU.

Keywords: Proton pump inhibitors, Clostridium difficile, Intensive care unit, Gastrointestinal hemorrhage, Stress, Histamine H2 antagonists, Risk assessment, Pneumonia, Physiological, Sucralfate

Core tip: To prevent gastrointestinal (GI) bleeding due to stress-related mucosal disease, critically ill patients are often routinely treated with proton pump inhibitors (PPI) or histamine 2 receptor antagonists (H2RA) for stress ulcer prophylaxis (SUP) in the intensive care unit (ICU). While major GI bleeding is currently rare in the ICU, SUP has not improved the overall survival of ICU patients in large clinical trials. Moreover, PPI and H2RA pose significant risks including toxicity, drug-drug-interactions and infectious complications (e.g., nosocomial pneumonia or Clostridium difficile-associated diarrhea). Instead of routine SUP, risk-adjusted algorithms may better balance benefits and threats of SUP in the ICU.